WHOSE CHOICE? PSYCHOTROPIC MEDICATION AND THE … · major tranquilizers, minor tranquilizers, antidepressants, stimulants, sedatives, and hypnotics with regularity, and reported

WHOSE CHOICE?PSYCHOTROPIC MEDICATION AND

THE ARMED FORCES

KARA MAHONEY*

There was only one catch and that was Catch-22, which specified that aconcern for one's own safety in the face of dangers that were real andimmediate was the process of a rational mind. Orr was crazy and couldbe grounded. All he had to do was ask; and as soon as he did, he wouldno longer be crazy and would have to fly more missions. Orr would becrazy to fly more missions and sane if he didn't, but if he was sane hehad to fly them. If he flew them he was crazy and didn't have to; but ifhe didn't want to he was sane and had to. Yossarian was moved verydeeply by the absolute simplicity of this clause of Catch-22 and let out arespectful whistle.

- Joseph Heller, Catch-22

I. INTRODUCTION

In military combat settings,' the use of psychotropic medications canbe highly desirable for myriad reasons: for performance enhancement; tostay awake and alert for long periods of time; as a way to calm nerves in

* Equal Justice Works AmeriCorps Legal Fellow, Inner City Law Center; A.B. English 2007,Georgetown University; J.D. 2012, University of Southern California Gould School of Law.

I In this paper, I will focus specifically on usage of psychotropic medications in the contextof combat, as opposed to other operational usage. Operational usage refers to the usage ofpsychotropic medications in "military operations other than combat, during peacetime or war,and on land, at sea, or in the air." DEP'TS OF THE NAVY & U.S. MARINE CORPS, COMBAT AND

OPERATIONAL STRESS CONTROL Glossary-4 (Dec. 2010), available athttp://www.med.navy.mil/sites/nmcsd/nccosc/coscConference/Documents/COSC%20MRCP 0 2ONTTP%20Doctrine.pdf.

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highly stressful situations; to ease the symptoms of depression or anxietydisorders; or to preserve the mental health of the service members2 incombat. Service members experience various coercive pressures in theirrelationships with mental health treatment and psychotropic medications.First, there are coercive pressures to hide mental health issues and to eitherignore or deny them. 3 If mental health problems become impossible toignore, there are pressures to quietly take psychotropic medications in lieuof any other mental health treatment, such as psychotherapy.4 There arealso coercive pressures to take medications like stimulants to performmissions lasting twenty-four hours or longer.5

Indeed, psychotropic medications are playing an increasingly largerrole in the everyday lives of deployed service members, for problemsranging from depression to insomnia to anxiety:

Walk into any of the larger-battalion-aide stations in Iraq or Afghanistantoday, and you'll find Prozac, Paxil and Zoloft to fight depression, aswell as Wellbutrin, Celexa, and Effexor. You'll see Valium to relaxmuscles (but also for sleep and combat stress) as well as Klonopin,Ativan, Restoril, and Xanax. There's Adderall and Ritalin for ADD andHaldol and Risperdal to treat psychosis; there's Seroquel, atsubtherapeutic doses, for sleep, along with Ambien and Lunesta. Sleep,of course, is a huge issue in any war. But in this one, there are enoughRed Bulls and Rip Its in the chow halls to light up the city of Kabul, andsoldiers often line their pockets with them before missions, creating acycle where they use caffeine to power up and sleep meds to powerdown. 6

Although the reasons for taking psychotropic medications varywidely throughout each branch of the armed forces and among individualunits and service members, psychotropic medication usage isdemonstrably a daily reality for many.

The military has acknowledged the problem and, as will be discussed,has made recommendations for dealing with the overmedication of itsservice members. Yet in practice, individual service members continue to

2 In the interest of clarity, the term "service member" is used to refer to any individualmember of any branch of the U.S. armed forces.

See infra Part VI.

4 See infra Part V.C.5 See infra Part V.F.6 Jennifer Senior, The Prozac, Paxil, Zoloft, Wellbutrin, Celexa, Effexor, Valium, Klonopin,

Ativan, Restoril, Xanax, Adderall, Ritalin, Haldol, Risperdal, Seroquel, Ambien, Lunesta, Elavil,Trazodone War, N.Y. MAG. (Feb. 06, 2011), http://nymag.com/news/ features/71277/.

See id.

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bear the full weight of choosing to take care of their individual healthwhile risking stigma and their careers, or choosing to hide their mentalhealth concerns while risking their long-term health, their safety, and thesafety of their fellow service members. In this paper, I will examine thehistorical and present usages of psychotropic medication in the armedforces, as well as the justifications and choices behind them. I will alsoexplore the longstanding stigmatization of mental health issues thatcontinues to pervade the armed forces. I will then examine the role ofcoercion in the military in general, and explore what effect-if any-coercion has on influencing service members to take psychotropicmedications. Finally, I will consider the unique position in which militaryphysicians find themselves in choosing whether to prescribe psychotropicmedications.

II. HISTORICAL USAGE OF PSYCHOTROPIC MEDICATIONS INTHE ARMED FORCES

Service members have long self-medicated to relieve the anxiety andinsomnia that result from the stresses of war, "from chloral hydrate andbromides in World War I to barbiturates in World War II and self-prescribed alcohol, cannabis, and heroin in Vietnam."8 Since World WarII, stimulants have been in widespread use to heighten preparedness andenhance the abilities of service members in combat.9 During World WarII, German, Japanese, and English soldiers used amphetamines asperformance enhancers to increase alertness, "but also to improvememory, concentration, physical strength, and endurance."10 Americanservice members used performance-enhancing drugs with frequencyduring the Vietnam War. For service members involved in long-rangereconnaissance patrol, Ritalin and Dexedrine "were standard-issue drugs"used to combat fatigue. Sedatives were used to relieve anxiety and tensionfor "paratroopers making low-altitude jumps" and "young soldiers whenguns were fired.""

The Vietnam War was the first armed conflict in which the UnitedStates was involved after the advent of modern psychopharmacology.Consequently, researchers took the opportunity to investigate the

8 Brett J. Schneider et al., Psychiatric Medications in Military Operations, in COMBAT ANDOPERATIONAL BEHAVIORAL HEALTH 151-52, 154 (Elspeth Cameron Ritchie ed., 2011).

9 Id.

1o Id.

1 IId.

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prevalence of prescribing psychotropic medications during the VietnamWar, recognizing that "combat is ordinarily regarded as one of the moststressful of human activities."1 2 The data was supplied by physiciansdeployed in Vietnam in the summer of 1967.13 The physicians detailed themental health justifications behind their prescriptions-most commonly,anxiety, insomnia, and combat fatigue ("shell shock")-as well as thefrequency with which they prescribed certain medications-about 12.5%of troops received prescriptions per year.14 The physicians prescribedmajor tranquilizers, minor tranquilizers, antidepressants, stimulants,sedatives, and hypnotics with regularity, and reported that they found thedrugs to be efficacious. 5

Despite the acceptance of prescribing psychotropic medication fordeployed service members since the Vietnam War, it was not until themid-1990s-when psychotropic medications with less deleterious sideeffects were introduced into the pharmaceutical landscape-thatpsychotropic medications began to be used with more frequency intreating ongoing psychiatric conditions like depression and anxiety incombat settings. Indeed, the evolution of psychotropic medication usagein the armed forces has "mirror[ed] changes in psychiatric practice and useof these medications in the military garrison environment and the civiliansector." 7

Prior to the Iraq War, service members were barred from deploying ifthey were taking psychotropic medications.' Yet despite the growingusage of psychotropic medications while deployed since then, the militaryhas been hesitant to issue directives regarding their recommended usage incombat settings.' 9 It was not until 2006 that the Department of Defense

12 WILLIAM E. DATEL & ARNOLD W. JOHNSON, JR., WALTER REED ARMY INST. OFRESEARCH & THE DIRECTORATE OF HEALTH CARE OPERATIONS, DEP'T OF THE ARMY,PSYCHOTROPIC MEDICATION IN VIETNAM 1 (1978), available at http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA097610.

13 Id.14 Id. at 5, 7.

15 Id. at 4, 9.16 Schneider et al., supra note 8, at 152.17 Id. at 160.18 Kim Murphy, A Medicated Military Faces Side Effects; As More Active-Duty Troops

Take Stimulants, Antidepressants and Other Drugs, Experts Suspect a Link to AberrantBehavior, L.A. TIMES, Apr. 8, 2012, at Al. However, beginning with the Vietnam War, servicemembers could be prescribed psychotropic medications while deployed. See DATEL &JOHNSON, supra note 12, at 5-6.

19 Schneider et al., supra note 8, at 154-56.

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released Policy Guidance for Deployment-Limiting Psychiatric Conditionsand Medications, which specified certain guidelines for when servicemembers on psychiatric medications may be certified for deployment. 2 0 itstated that service members taking psychotropic medications must bestable for three months on the medications before being cleared fordeployment. 2 1 Commanders were directed to determine fitness fordeployment on a case-by-case basis; service members who can "performtheir assigned duties, are medically stable, and are not a danger tothemselves or others should be considered fit and suitable for worldwidedeployment regardless of their psychiatric diagnoses." 22

III. PRESENT USAGE OF PSYCHOTROPIC MEDICATIONS IN THEARMED FORCES

In the present day,2 3 "a sizable and growing number of U.S. combattroops are taking daily doses of antidepressants," due to the repeated andlengthy tours in Iraq and Afghanistan. 2 4 According to a 2007 anonymoussurvey of U.S. troops taken by the Army's Fifth Mental Health AdvisoryTeam,25 "about 12% of combat troops in Iraq and 17% of those inAfghanistan are taking prescription antidepressants or sleeping pills tohelp them cope," 26 which adds up to approximately 20,000 troops total.The Los Angeles Times reported that "more than 110,000 active-dutyArmy troops [in 2011] were taking prescribed antidepressants, narcotics,sedatives, antipsychotics and anti-anxiety drugs .... Nearly 8% of theactive-duty Army is now on sedatives and more than 6% is on

20 Non-deployable service members include those who are being treated for psychosis orbipolar disorder, those taking medications (such as lithium) that require laboratory monitoring,and those taking antipsychotic medications. Waivers for certain disqualifying conditions may berequested. Memorandum from William Winkenwerder, Jr., MD, Assistant Sec'y of Def., toSec'y of the Army, Sec'y of the Navy, Sec'y of the Air Force, & Chairman of the Joint Chiefs ofStaff 4.2.4, 4.2.3 (Nov. 7, 2006), available at http://www.health.mil/Libraries/HAPoliciesandGuidelines/Guidance_20061107_deplo_1imitingpsyc cond.pdf [hereinafterWinkenwerder Memorandum].

21 Id. at 4.1.4.4.22 DEP'TS OF THE NAVY & U.S. MARINE CORPS, supra note 1, at 5-4.

23 See infra text accompanying notes 128-30.24 Mark Thompson, America's Medicated Army, TIME (Jun. 05, 2008),

http://www.time.com/time/magazine/article/0,9171,1812055-1,00.html.25 MENTAL HEALTH ADVISORY TEAM V, OPERATION IRAQI FREEDOM 06-08: IRAQ,

OPERATION ENDURING FREEDOM 8: AFGHANISTAN 144, 203 (2008), available at

http://www.armymedicine.army.mil/reports/mhat/mhatv/MHATV_OlFandOEF-Redacted.pdf.26 Thompson, America's Medicated Army, supra note 24.

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antidepressants-an eightfold increase since 2005."27Due to the stigma 28 attached to mental health needs and service

members' probable reluctance to report their intake, these statistics likelyunderestimate the use of psychotropic medications in the Army. 29 Usageof antidepressants like Prozac and Zoloft and sleeping pills like Ambien iswidespread not only to ease the anxieties and pressures straining themental health of individual service members, "but also to enable thealready strapped Army to preserve its most precious resource: soldiers onthe front lines."3 0 Before enlisting, service members are prescreened formental illnesses, 31 but there is continuing debate over the need to screenmore effectively for mental health concerns before service members aredeployed.32 Indeed, whereas previously taking psychotropic medicationswhile in combat was prohibited, now service members are prescribed,and perhaps even encouraged, to take them while deployed so as to helpconserve the limited number of trained service members available for

27 Murphy, supra note 18. However, the military asserts that "[e]ven given the increasedtrend, there does not appear to be an inappropriate increase in the use of psychotropicmedication given the likely increase in rates of psychological stress. It is likely that the increaseduse, both in theater and in garrison, reflects appropriate professional judgment and prescribing."Memorandum from the Def. Health Bd. Psychological Health External Advisory Subcomm. tothe Off. of the Assistant Sec'y of Def. for Health Affairs 26 (Aug. 17, 2010), available athttp://www.govexec.com/pdfs/092711bbl.pdf [hereinafter Def. Health Bd. Memorandum].

28 See infra Part 0.29 Thompson, America's Medicated Army, supra note 24.

30 I31 There are two components to assessing psychological fitness for potential recruits:

(1) assessing aptitude through the Armed Services Vocational Aptitude Battery and (2) adetermination of educational achievement. Robert Cardona & Elspeth Cameron Ritchie,Psychological Screening of Recruits Prior to Accession in the US Military in RECRUITMEDICINE 304 (Bernard L. DeKoning ed., 2006), available at https://ke.army.mil/bordeninstitute/published volumes/recruitmedicine/RM-ch I 6.pdf.

32 See, e.g., Lisa Chedekel & Matthew Kauffman, Special Report: Mentally Unfit, Forcedto Fight, HARTFORD COURANT (May 14, 2006), http://www.courant.com/news/special-reports/hc-unfit05l5.artmayl4,0,5622628.story; Charley Keyes, Army To Implement New MentalHealth Screening Procedures, CNN.COM (Jan. 19, 2011), http://articles.cnn.com/2011-01-19/us/military.mental.health- Isuicidal-ideation-predeployment-screening-process-combat-stress?_s=PM:US; James Dao, Military Study Finds Benefits in Mental Health Screening, N.Y.TIMES (Jan. 18, 2011), http://www.nytimes.com/2011/01/19/us/19military.html; MarkThompson, Army Mental Health: Better Screening Yields Better Results, TIME (Apr. 17, 2011),http://battleland.blogs.time.com/2011/04/17/army-mental-health-better-screening-yields-better-results/; Neal Conan, Grading The Military's Mental Health Screenings, NPR.ORG (Mar. 20,2012), http://www.npr.org/2012/03/20/149002197/grading-the-militarys-mental-health-screenings.

33 Thompson, America's Medicated Army, supra note 24.

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missions.34

A. CHALLENGES UNIQUE TO THE MILITARY'S USE OF PSYCHOTROPIC

MEDICATIONS

Service members in combat settings endure stressors such as "IEDs[improvised explosive devices], ambushes, severe sleep deprivation, [and]direct combat"35 and could experience "nearly being killed by an IEDblast, being ambushed and pinned down by small arms fire during groundcombat, or witnessing the death of a shipmate in a fire below decks." 36

Such challenges faced by military personnel in combat settings canseemingly justify the usage of psychotropic medications, the usage ofwhich in civilian life might not seem as justifiable.

However, psychotropic medicines were not created to cope with warbut rather to treat civilian mental disorders. Professor Michael H. Shapiroobserves, "[i]f we are sick and medical technology restores us to our initialbaseline, we are obviously enhanced in some sense,"37 whereas the use ofpsychotropic medications for the enhancement of one's ability to remainalert in combat settings is certainly not restoring an individual to abaseline. Instead, such usage seeks to propel an individual's capabilities-for example, to remain awake for twenty-four hours or more in order tocarry out a mission-beyond what an average human withoutenhancement could competently handle.38 Yet the aforementioned life-threatening conditions that combat service members endure perhaps justifystepping outside the natural scope of a disorder treatment model. Surely astrong argument for using psychotropic medications exists if doing sowould increase a service member's chance of surviving a particularmission.

39

34 See infra Parts 0, and OA.3 Elspeth Cameron Ritchie, Address at The PA 2nd Annual Veterans Conference:

Psychological Effects of War Since 9/11 4 (Mar. 21-22, 2012), available athttp://www.drexelmed.edu/drexel-pdf/program-behavioral-health/conference-handout-veterans-psychological-effects-war.pdf [hereinafter Ritchie Address].

36 DEP'TS OF THE NAVY & U.S. MARINE CORPS, supra note I at 2-2.

3 MICHAEL H. SHAPIRO ET AL., CASES, MATERIALS AND PROBLEMS ON BIOETHICS AND

LAW 1431 (2d ed. 2003).3 See NAVAL STRIKE & WARFARE CTR., PERFORMANCE MAINTENANCE DURING

CONTINUOUS FLIGHT OPERATIONS: A GUIDE FOR FLIGHT SURGEONS (2000), available athttp://www.med.navy.mil/directives/Pub/6410.pdf [hereinafter NAVAL STRIKE & WARFARECTR.].

39 See Brad Knickerbocker, Military Looks to Drugs for Battle Readiness, CHRISTIAN SCLMONITOR (Aug. 9, 2002), http://www.csmonitor.com/2002/0809/p01 s04-usmi.html.

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The President's Council on Bioethics faced the issue of usingpsychotropic medications in a military context in its 2003 report onenhancement drugs.4 0 The Council wrestled with the notion that ensuringthat service members perform in a "certain special superior" manner is"not only edifying but urgent," due to the fact that they perform under"moments of extreme peril and consequence ... when superiorperformance is a matter of life or death." ' Regardless of any individualhesitations about taking medication, "life or death" situations would likelyencourage most people to take a performance-enhancing drug if it wouldimprove one's chances of survival. Service members in suchcircumstances might agree to take a performance-enhancing medicationand justifiably allow themselves to be treated as "alterable artifacts . .. inorder to 'get the job done.'"42 Indeed, the military views service membersas such,43 and for individual service members, obeying commands anddoing what is best for the unit and military in general is ingrained intotheir psyches from the very beginnings of their military careers.

IV. AUTONOMY AND MILITARY CULTURE

From the start of their military careers, service members areencouraged to form a group mentality, to serve selflessly and to privilegethe health of the group over the health of themselves as individuals.44

40 PRESIDENT'S COUNCIL ON BIOETHICS, BEYOND THERAPY: BIOTECHNOLOGY AND THE

PURSUIT OF HAPPINESS (2003).

41 Id. at 154.

42 Id.43 See Catherine L. Annas & George J. Annas, Enhancing the Fighting Force: Medical

Research on American Soldiers, 25 J. CONTEMP. HEALTH L. & POL'Y 283, 289-90 (2009)(citing PRESIDENT'S COUNCIL ON BIOETHICS, supra note 40, and noting that as long as soldiersbecome "de facto robots, enhancements are acceptable .... Such biotechnical interventionsmight improve performance in a just cause .... .").

4The values of each individual service branch reflects an attitude of group over individual.E.g., Our Values, U.S. AIR FORCE, http://www.airforce.com/leam-about/our-values (last visitedApr. 13, 2013) (citing "service before self' as its second core value); The Army Values, U.S.ARMY, http://www.army.mil/values/ (last visited Apr. 13, 2013) (citing "loyalty, duty, andselfless service" among its core values); Core Values, U.S. COAST GUARD,http://www.uscg.mil/hq/osc/values.asp (last visited Apr. 13, 2013) (citing "Greater Good of theCoast Guard" as a core value); Principles & Values: Semper Fidelis, U.S. MARINE CORPS,http://www.marines.com/history-heritage/principles-values (last visited Apr. 13, 2013) (citing itsmotto, Semper Fidelis, as the guide for Marines "to remain faithful to the mission at hand, toeach other, to the Corps and to country, no matter what"); Core Values of the Navy, U.S. NAVY,http://www.navy.mil/navydata/navy_1egacy-hr.asp?id=193 (last visited Apr. 13, 2013) (citing aserviceperson's "commitment" to "obey the orders . .. up and down the chain of command" as acore value).

WHOSE CHOICE?

Presumably to encourage individual fitness, group bonding, obedience andsubmission to commanding officers, and to hasten development fromcivilian to service member, recruits are inundated with mental, emotional,and physical messages of intolerance for weakness.4 5 Service memberslearn that any concerns of mental or physical health should be kept tooneself.46 The military emphasizes that "[d]iscipline is the means by whichleaders at all levels communicate relentlessly to subordinates the entire setof [knowledge, skills, and attitudes] they need to absorb and to master inorder to answer every threat they will face with an immediate andresounding, 'Yes, I can handle this!"' 4 7 The nature of the military'smissions means that physical and mental weakness on behalf of anyservice members can put people's lives in danger.

One example of indoctrinating service members with an intolerancefor weakness is the process by which Marine recruits in basic trainingundergo visual bodily inspections. A former Marine I spoke withdescribed the experience:

All the privates stand completely naked in front of the officer. You spinin a circle with your arms held straight in front of you, lifting your kneesto your chest, while repeatedly shouting, "Sir, this recruit has nomedical, dental, or psychological problems to report at this time, Sir!'48

From the outset of one's time in the military, an individual is taughtto push aside psychological concerns in favor of a fully positive report toone's superior. The public performance of demonstrating one's physicaland mental fitness, in front of a crowd of officers and fellow recruits, doesnot readily facilitate being forthcoming with any concerns.

A. OBEYING SUPERIORS AND LEARNING TO TAKE COMMANDS

Service members are trained to obey and submit to their commandingofficers from the moment they enter the military. 49 The military maintainsthat the nature of its missions necessitates a hierarchical structure in whichservice members who fail to obey the orders of commanding officers arepenalized.50 Commanding officers need to be able to "trust that every unit

45 DEP'TS OF THE NAVY & U.S. MARINE CORPS, supra note I at 5-5.46 Id.

47 Id. at 2-12.48 Interview with Steve, former U.S. Marine Corps member, in L.A., Cal. (Sept. 23, 2011).49 10 U.S.C. § 502 (requiring people enlisting in the military to swear that they "will obey

the orders of the ... officers appointed over [them]").50 10 U.S.C. § 892 (detailing that a court martial may direct disciplinary actions for Service

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member will perform effectively during every future challenge andperform their assigned roles without limitations," 5 and indoctrinatingservice members with messages of selflessness and imperatives to obeycommands appears to be the military's way of accomplishing that.

B. SOCIAL COHESION AND THE TRANSFORMATION FROM "I" TO "WE"

All branches of the armed forces emphasize the loss of self for thebenefit of one's fellow service members.52 In detailing the transformationsthat one undergoes in the process of becoming a Marine, the Marine Corpsstates that for recruits,

[Q]uitting is not an option, as the consequences are too great, not just forthemselves-but for their entire platoon.... It's not just respect forothers that Marines develop; it's a genuine concern for their well-being.Training with, enduring alongside and relying on those to their left andright during such a challenging experience redirects their focus from selfto that of accomplishing missions together.53

All service members are trained to think not of themselves, but oftheir fellow service members and the greater wellbeing of the group andthe mission at hand.54 The military notes that fostering unit cohesion leadsservice members to "respond to a threat situation with a positive, 'Yes, Ican handle this!' because in a cohesive unit, the 'I' can be replaced with'we. '"' No service members want to derail the group's mission or letdown their fellow service members, particularly if they have beenrepeatedly proclaiming that they are physically and mentally fit.

For modem-day service members, joining the armed forces isvoluntary,56 which may lend itself to the argument that those who enlistknowingly consent to self-sacrifice for the good of the group. However,potential service members can never know what the stress of war is like

Members who fail to obey orders or regulations from a superior or who are derelict in theperformance of their duties).

5I DEP'TS OF THE NAVY & U.S. MARINE CORPS, supra note I at 6-2.52 See supra text accompanying note 44.

Marine Corps Transformation, U.S. MARINE CORPS, http://www.marines.com/becoming-a-marine/transformation (last visited Apr. 13, 2013).

54 DEP'TS OF THE NAVY & U.S. MARINE CORPS, supra note I at 2-11.Id. at 2-10.

56 The introduction of the all-volunteer force came in 1973 with the end of the draft.BERNARD ROSTKER, RAND CORPORATION, I WANT YOU!: THE EVOLUTION OF THE ALL-VOLUNTEER FORCE 2 (2006), available at http://www.rand.org/pubs/monographs/2007/RANDMG265.pdf.

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and what their reactions to such stress will be until they experience it.Whereas the valuing of a group over one's individual interests may bevital to accomplishing the goals of the United States Armed Forces, on anindividual level it can mean dealing with crippling mental illness aloneand can potentially do more harm to the group than good. For example, ifa Marine is trying to push aside concerns of combat-related anxiety anddepression-thinking that it is in the best interest of the platoon-eventually the anxiety could overtake the Marine while in a vulnerableposition, putting not only that Marine's life in danger, but the lives of theother platoon members as well.s? Service members who choose tomedicate with psychotropic medications are reacting to the practicalcircumstances in which they find themselves and treating themselves inthe most seemingly efficient manner. Yet psychotropic medication israrely, if ever, the only recommended mental health treatment forindividuals; and if it is the only option for a service member-eitherbecause of a fear that voicing mental health concerns could lead to stigmaor hinder career aspirations, or because of a lack of mental healthprofessionals from whom to seek alternative help-the service memberwill likely end up suffering silently, with possible negativeconsequences.ss

C. OVERVIEW OF MENTAL HEALTH CARE TREATMENT FOR DEPLOYED

SERVICE MEMBERS

The armed forces have acknowledged that they lack a uniform systemfor providing mental health care treatment, including the prescription ofpsychotropic medications, and cite the "transient nature of the militarypopulation" that "makes continuity of care a challenge for militarymedicine." 59

As opposed to psychiatrists or psychologists-medical professionalswho typically oversee the use of psychotropic medications for civilians-primary care physicians and medical technicians "provide the majority of

See, e.g., Murphy, supra note 1818 (explaining that compared to the general population,"'[t]he big difference is these are people who have access to loaded weapons, or haveresponsibility for protecting other individuals who are in harm's way,' said Grace Jackson, aformer Navy staff psychiatrist who resigned her commission in 2002, in part out of concerns thatmilitary psychiatrists even then were handing out too many pills").

58 See JOINT MENTAL HEALTH ADVISORY TEAM 7, OPERATION ENDURING FREEDOM

2010: AFGHANISTAN 73 (2011), available at http://www.armymedicine.army.miI/reports/mhat/mhat vii/J MHAT_7.pdf; see also Thompson, America's Medicated Army, supra note 24.

59 Def. Health Bd. Memorandum, supra note 27 at 15.

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psychological health care in-theater" 60 and consequently often lack thetraining of a skilled mental health care provider. Psychological help isgenerally offered under the guise of a primary care setting due to thedearth of deployed mental health specialists, and also to counteract anystigma associated with obtaining mental health treatment.6 1

Due to circumstances of combat, which often include being in remotelocations, service members who receive prescriptions for mental healthproblems do not have routine follow-up visits with doctors as do thosecivilians who receive the same psychotropic medicines; according to aformer Army sergeant, "In the civilian world, when you have a problem,you go to the doctor, and you have therapy followed up by somemedication. In Iraq, you see the doctor only once or twice, but youcontinue to get drugs constantly." 62 According to an investigative reportby The Hartford Courant,63 "[M]ilitary doctors treating combat stresssymptoms were sending some soldiers back to the front lines after rest anda three-day regimen of medication despite evidence that it typically takestwo to six weeks for the prescribed medications to begin working."64

In response to the acknowledged need for better mental health caresupport, some branches of the armed forces have created special teamsdedicated to such treatment, including the deployment of a Navy Medicineteam for "conducting mental health surveillance, command consultation,and coordinating mental health care for sailors . . . ."65 Additionally, theArmy has significantly increased its staffing ratio of behavioral healthpersonnel to service members, from 1:1123 in May 2009 to 1:646 inAugust 2010.66 (For comparison, the military's Mental Health AdvisoryTeam recommends 1:700). However, despite recent efforts to improvethe situation, service members often find themselves unable to obtainadequate treatment. The Joint Mental Health Advisory Team's report for2009 noted that for "[s]ervice members who need help with psychologicaland behavioral health concerns, only about 50% seek it, and of those whodo, only 42% receive it."68 Reported reasons for not getting help included

60 Id. at 32.61 Id. at 12.62 Thompson, America's Medicated Army, supra note 24.63 Chedekel & Kauffman, supra note 32.

Def. Health Bd. Memorandum, supra note 27, at 2.65 Id. at 32.66 Ritchie Address, supra note 35, at 18.67 d.

6Def. Health Bd. Memorandum, supra note 27, at 11.

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fear of stigma (50% or more), difficulty getting time off (40%), lack ofaccess (40%), and leaders discouraged use of mental health services(2 1%).69

D. How SERVICE MEMBERS RECEIVE PSYCHOTROPIC MEDICATIONS

Service members can access psychotropic medications in a variety ofways: pre-deployment, they can fill prescription medications for up to 180days; they can bring prescription drugs that were prescribed by privatesector providers; they can access them at military treatment facilities,which receive bulk shipments of medications; friends and family can mailmedications; technicians can dispense medications to service members infar-forward combat areas; and fellow service members can distributethem.70

Coupled with the varied methods of obtaining medications, themilitary lacks a unified pharmacy database for tracking individuals'prescriptions.7 1 This makes it possible for service members to haveprescriptions for and to take several different medications at once,increasing the risk of excessive medication and adverse side effects of

72medication interactions.

E. SIDE EFFECTS OF TAKING PSYCHOTROPIC MEDICATIONS

Regardless of any benefit taking a stimulant or depressant wouldhave for a service member and for the military generally, the side effectsof such medications cannot be ignored. With amphetamine use, anindividual may experience fast heartbeat, tremors, dizziness, headache,and insomnia, all of which could end up being counterproductive to theservice member's mission, not to mention the initial reason-anxiety, forexample-for taking the medication. Dexedrine is an amphetamine

Ritchie Address, supra note 35, at 12.70 Def. Health Bd. Memorandum, supra note 27, at 18.7 Interestingly, the military points out that increased tracking and identification can result

in "unintended consequences" such as "stigmatization of the Service member and his or herfamily." Id. at 2-3.

72 One distressing example is that of Chad Oligschlaeger, a young Marine who did twotours in Iraq and came home "complaining of nightmares and hallucinations. He was takingtrazodone, fluoxetine, Seroquel, Lorazepam and propranolol, among other medications."Oligschlaeger died two months before he was scheduled to leave the Marines; his death wasconcluded to have been "accidental due to multiple-drug toxicity-interactions among too manydrugs." Murphy, supra note 18.

Annas & Annas, supra note 43 at 293.

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officially sanctioned by the United States Air Force for pilot use. In itsguide to performance maintenance, 7 4 the Navy acknowledged that:

[F]atigue in sustained, continuous naval flight operations75 is expectedand can lead to poor flight performance and increased aircraft mishappotential. ... The uses of sleep, combat naps, proper nutrition, andcaffeine are currently approved and accepted ways flight surgeons canrecommend to prevent and manage fatigue. However, in sustained andcontinuous operations these methods may be insufficient to preventfatigue and maintain combat-ready performance. Properly administereduse of stimulant and sedative medications, i.e., Dexedrine, Ambien, andRestoril, is an additional measure flight surgeons can recommend tomanage fatigue and maintain pilot performance in continuous, sustainednaval flight operations. 76

Yet in its prescribing information, Dexedrine's manufacturer cautionsthat "[a]mphetamines may impair the ability .. . to engage in potentiallyhazardous activities such as operating machinery or vehicles ... ." Themilitary recognizes this, noting that:

[Certain mental health] treatments can impact fitness for duty anddeployment either because the side effects of the treatment . .. mayinterfere with adequate performance of duties or because suddenwithdrawal of the treatment during deployment because it is no longeravailable may lead to serious worsening of the underlying stresssymptoms or to other withdrawal symptoms.78

The military refers not only to psychotropic medications as possiblyinterfering with the performance of duties, but also to all "psychologicaltreatments," 79 a phrase that it does not expand upon but which presumablyincludes psychotherapy.

Beyond the Air Force, "the medications-combined with the war'sother stressors-created unfit soldiers: 'There were more than a fewconvoys going out in a total daze."' 80 An Army major commented that he

74 NAVAL STRIKE & WARFARE CTR., supra note 39.Continuous operations are those lasting longer than twenty-four hours; they do not

necessarily involve more working hours for individuals, but the Navy admits that during suchoperations, "sleep may be intermittent, broken, and unrestorative." Id. at 3. Sustained operationsare those that require individuals to work longer than twenty-four hours at a time, until themission is complete, during which time "sleep deprivation is common." Id.

76 Id. at 6.

Annas & Annas, supra note 43, at 293.78 DEP'TS OF THE NAVY & U.S. MARINE CORPS, supra note 1, at 6-6 to 6-7.79 Id.80 Thompson, America's Medicated Army, supra note 24.

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felt "like people with my symptoms are becoming the majority of theArmy ... [fJeeling anxious when you don't have a reason to, being a littledepressed, having low-grade anhedonia, not sleeping well-this is the newnormal for those of us who've been repeatedly deployed." 8' Moreover,"[a]bout a third of soldiers in Afghanistan and Iraq say they can't see amental-health professional when they need to," and surges in troopnumbers have not been accompanied by corresponding surges in mental-health workers. 82 This further compounds the difficulty in seeking andobtaining adequate mental health care treatment.8 3 The military admits that"there may be an underuse of alternative treatment strategies, particularlyin theater." 84

Moreover, those service members who are using psychotropicmedications may not have the benefit of physician oversight to monitortheir psychotropic medication intake. The military's Defense HealthBoard, a federal advisory committee to the Secretary of Defense, hasacknowledged that "[i]n the military setting, care has to be taken to ensurethat the effects of polypharmacy8 5 do not impair readiness. Theappropriateness of polypharmacy might differ between civilian andmilitary settings." 86 Although the Defense Department utilizes anelectronic health records system, access to it may be limited, particularlyin combat settings.87 Even with access to the system, prescribing providersand technicians "may not uniformly code for psychologicalconditions . . . [and] avoid diagnostic codes that may implicate a moreserious mental health issue in an environment with ongoing combat."88

Some prescribers have even miscoded mental health diagnoses to shieldservice members "from potential stigmatization or discrimination."8 9

81 Senior, supra note 6.82 Thompson, America's Medicated Army, supra note 24.83 Id.

84 Def. Health Bd. Memorandum, supra note 27, at 27.85 Polypharmacy refers to "the use of multiple medications by a patient regardless of the

route of receipt. It can refer to too many forms of medication or more drugs than are clinicallyindicated or warranted." Def. Health Bd. Memorandum, supra note 27, at 9.

86 Id

87 Id. at 16.88Id89 d

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V. THE STIGMA OF MENTAL HEALTH ISSUES IN THE ARMEDFORCES

As a service member, admitting that it may be necessary to seekmedical treatment for physical or mental health concerns can be acomplicated decision. By its very nature, the work of the militarystigmatizes health concerns: the ideal service member is physically fit,fearless, and mentally and emotionally stable enough to handle intense,potentially life-threatening situations.90 The military admits that mentalhealth stigma arises as a result of "an admiration for strength in body,mind, and spirit, and a similar intolerance for weakness of any kind." 9'The military goes on to say that such an attitude is "necessary forindividuals and units in the military to perform challenging missions underdifficult conditions."92 However, these attitudes can:

Cause significant and unintended harm if they prevent individuals fromadmitting to themselves or others that they are wounded, injured, or illfor fear of appearing weak. The wish to avoid any appearance ofweakness can motivate Service members to hide not only their stresssymptoms, but also their physical health problems.93

Thus, it appears to be up to the individual service member to wrestlewith the competing messages that are received from commanding officers:do not show any weakness, but know that you may be doing yourselffurther harm by not displaying weakness and seeking help if you areseriously hurt. Female service members are especially vulnerable to thestigma of seeking mental health treatment because they are underheightened pressure to appear as fit and as tough as their malecounterparts. 4

The military has a long history of stigmatizing mental health issuesand the circumstances that surround mental illness. Prior to the recognitionof "shell shock," combat fatigue, and PTSD, service members whoendured traumatic experiences and consequently suffered tremendousmental and emotional strain were labeled as having "hysteria." As themilitary describes, this term was "deliberately chosen to produce shame inthe young men given that label. Hysteria literally meant 'disturbances of

90 DEP'TS OF THE NAVY & U.S. MARINE CORPS, supra note 1, at 5-5.

9 Id.92 Id.

93 Id.

94 See Jennifer Boldry et al., Gender Stereotypes and the Evaluation of Men and Women inMilitary Training, 57 J. OF SOC. ISSUES 689, 690 (2001).

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the uterus;' even uneducated young European men in 1916 knew thatbeing compared to a female reproductive organ was feminizing andshameful."95

The attitude of viewing mental health issues as sources of shame andsignals of character weakness prevailed throughout the twentieth centuryand "intentionally increased the social stigma attached to psychologicalproblems of all kinds."96 Instead of recognizing psychological trauma as anatural result of witnessing traumatic events, the prevailing attitude in themilitary was "that only morally weak or unmotivated individualsdevelop[ed] significant problems because of stress."9 Despite the stridesbeing made toward reducing the stigma of mental health issues, stigmacontinues to operate both on broad, institutional levels in the military, aswell as on an individual level. 98

A. INSTITUTIONAL STIGMA

Institutional stigma of mental health issues has been built into andcontinues to pervade the military system, an issue that the militaryrecognizes and is attempting to change.99 The Departments of the Navyand the Marine Corps acknowledge that through their policies, procedures,and organizational attitude, fundamental system-wide stigma "is the onethat is most tangible and most based on fact-the real harm that can occurto a military career or to future employability because of having beendiagnosed and treated for a mental health problem." 00

For example, "[a]pplications for security clearances and licensure in anumber of fields . . . still include questions asking whether the individualhas ever been treated for a mental illness."' 0' Although having a mentalhealth record will not disqualify an applicant immediately, "it does triggera requirement for additional documentation and possibly a currentpsychiatric evaluation to determine fitness and suitability."' 0 2

Consequently, service members hoping to advance in careers-military orcivilian-that require security clearances might understandably be

95 DEP'TS OF THE NAVY & U.S. MARINE CORPS, supra note I at 5-6 to 5-7.96 Id. at 1-5 (emphasis in original).97Id98 Id. at 5-2 to 5-4.

99 Id. at 5-4.100 Id.lot Id.102 Id

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reluctant to admit to mental health problems with the knowledge that sucha record could derail a future career.' 0 3

B. INDIVIDUAL STIGMA

On an individual level, stigma operates through the prevailingattitudes of one's environment; peers reinforce stigma through the"language and behaviors that groups use to include or excludemembers."' 0 4 Stigmatized individuals face isolation and ridicule from theirpeers-in addition to the shame they likely inflict on themselves-whichis an especially frightening prospect for service members, for whom socialcohesion and camaraderie is of paramount importance to completingmissions.' Service members do not want to be perceived as mentallyunstable and in a position to put fellow service members at risk.'06 If thereis knowledge of a comrade taking pills, this can lead to distrust of thatindividual, and fellow service members might begin to question thatindividual's ability to complete duties and perform under intense combatpressure.lo7

The result of these stigmas is that individuals who believe they needmental health treatment might avoid seeking such treatment due to a fearof being distrusted or shunned by their fellow service members; instead,they may simply hope that their problems will dissipate.'08 On the otherhand, individuals in need of mental health treatment might have sointernalized stigmatization of mental health problems that they do notrealize their need for help "until marriages have been lost, violations of theUniform Code of Military Justice have been committed, or other life orcareer damage has been done."' 09

C. CONSEQUENCES OF STIGMA

As a result of institutional and individual stigma, "[m]embers of allServices have reported a reluctance to seek help for stress or mental healthproblems for fear of being branded as weak by their peers and

lo3 Id.

104 Id. at 5-3.105 Id. at 3-20, 5-2 to 5-3.106 Id. at 5-5.

107 Id. at 6-10.ls Id. at 1-13.109 Id.

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superiors." 0 Even for physical health ailments, the pressure to be and tobe perceived as superhumanly physically fit is intense and can result inservice members' reluctance or failure to seek treatments that involvetaking medications, such as painkillers."'

Consequently, stigma creates disincentives to seeking more "visible"mental health treatment such as seeing a therapist-which is oftenimpossible in combat zones even if one were to seek such help-orrequesting a change of duty or leave." 2 Instead, those wishing to confrontmental health issues in a discreet manner might prefer to quietly take apsychotropic medication. Or, service members exhibiting signs of mentaldistress may be directed by their commanding officers to seek aprescription for psychotropic medication. However, the threat of stigmamight prove so great that a service member will never seek treatment ofany kind, nor admit a need for help, and "[w]ithout early treatment,problems are more likely to become chronic and entrenched."" 3

VI. CONSEQUENCES OF AN OVERMEDICATED MILITARY

As a result of a military culture intolerant of weakness butsimultaneously stigmatizing treatment for mental disorders, soldiers arefrequently given medication while the underlying causes of their mentalstrains remain unaddressed.

A. CYCLICAL NATURE OF "Go" AND "NO-GO" PILL USAGE

In the military, "go pills" denote those psychotropic medications usedto keep personnel awake and alert during particularly long missions orthose conducted during normal sleeping hours."14 To ensure thatindividuals using "go pills" eventually are able to rest, the effects of theamphetamines must be counteracted with "no-go pills," which aid military

11o Id. at 3-7.II Id. at 5-5. The Departments of the Navy and Marine Corps report, "Less well-known,

but of equal importance, is the stigma in certain segments of the military associated with seekinghelp even for a physical health problem, especially if it is an injury or illness not caused bydirect enemy action. Particularly in ground combat communities in which toughness andstoicism are highly prized, Marines and Sailors may suffer through entire deployments with mildto moderate physical health problems they are unwilling to report to their leaders or medicalpersonnel for fear of being seen as less tough or of being removed from their duties and units."Id. at 3-7 to 3-8 (emphasis in original).

112 Thompson, America 's Medicated Army, supra note 25.

1 DEP'TS OF THE NAVY & U.S. MARINE CORPS, supra note 1, at 1-6.114 NAVAL STRIKE & WARFARE CTR., supra note 39, at 10.

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personnel in getting to sleep in-between missions.'15 As a result of therepeated usage of both go and no-go pills, service members' sleep cyclesand fatigue levels are reasonably distorted and such usage can have severeconsequences for service members, who may become addicted to a "cyclicuse of a stimulant/sedative combination."I16

B. LONG-TERM ECONOMIC CONSEQUENCES

Using psychotropic medications to treat deployed service memberswith mental health problems saves the military money it would otherwisespend to train and deploy replacement service members, but the projectedlong-term effects are troubling. Because service members are beingredeployed into combat with more frequency, "the number of soldiersrequiring long-term mental-health services soars,"" 17 and the militaryeventually will feel the effects of its reliance on psychotropicmedications-such as antidepressants and sleeping aids-to treat andcontinuously redeploy service members." 8

According to the Army, "Defense Department spending on Ambien,a popular sleep aid, and Seroquel, an antipsychotic, has doubled since2007, ... while spending on Topamax, an anti-convulsant medicationoften used for migraines, quadrupled; amphetamine prescriptions havedoubled, too."" 9 In 2010, the Military Times newspaper exposed thenumbers behind Defense Department spending on psychiatric and painmedications: the Defense Logistics Agencyl 2 0 had spent $1.1 billion from2001 to 2009.121 The investigation found that during that period, the use ofpsychiatric medications increased seventy-six percent, and that at least onein six service members was on at least one form of a psychotropic

115 Id.116 Id. at 9.117 Thompson, America's Medicated Army, supra note 24.118 See generally Linda J. Bilmes, Current and Projected Future Costs of Caring for

Veterans of the Iraq and Afghanistan Wars, COSTS OF WAR (June 13, 2011),http://costsofwar.org/sites/default/files/articles/52/attachments/Bilmes%2OVeterans%20Costs.pdf.

119 Senior, supra note 6.120,"The Defense Logistics Agency is the Department of Defense's largest logistics combat

support agency.. .. " About the Defense Logistics Agency, DEF. LOGISTICS AGENCY,http://www.dla.mil/pages/aboutcdla.aspx (last visited Apr. 13, 2013).

121 Andrew Tilghman & Brendan McGarry, Medicating the Military: Use of PsychiatricDrugs Has Spiked; Concerns Surface About Suicide, Other Dangers, ARMY TIMES (Mar. 17,2010), http://www.armytimes.com/news/2010/03/military-psychiatric-drugs_031710w.

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medication.122Despite exorbitant associated costs,' 2 3 the military is focused on

redeploying troops as opposed to recruiting, training, and deploying newtroops, which has more short-term costs.124 Projected overall medical costsfor the years 2011 to 2020 for treating veterans through the VeteransHealth Administration ranges from $40 billion to $54 billion.' 2 5

Economists Joseph Stiglitz and Linda Bilmes estimate that "the long-termcost of providing medical care and disability compensation for theseveterans . . . [will be] between $589 billion and $934 billion ....Bilmes also noted that:

[V]eterans from the recent wars are utilizing VA medical services andapplying for disability benefits at much higher rates than in previouswars. The higher medical usage is the result of several factors,including . . .higher incidence of post-traumatic stress disorder and othermental health problems [and] more veterans who are willing to seektreatment for mental health ailments . . . ."'27

122 Id.

123 In addition to spending on psychotropic medications, the military must consider the costof future mental health treatment for the severe psychological problems associated withconstantly redeploying troops. See generally Bilmes, supra note 118.

124 For example, "A trained service member who separates from the military must bereplaced by more than one accession [new recruit] to account for recruits who separate duringtraining or during their first few years of service." CONG. BUDGET OFF., RECRUITING,RETENTION, AND FUTURE LEVELS OF MILITARY PERSONNEL XII (2006), available athttp://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/76xx/doc7626/10-05-recruiting.pdf.

125 CONG. BUDGET OFF., POTENTIAL COSTS OF VETERANS' HEALTH CARE 27-29 (2010),available at http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/1 I8xx/doc 11811/2010_10_7_vahealthcare.pdf.

126 The True Cost of War: Hearing Before the Committee on Veterans' Affairs, U.S. Houseof Representatives, I1 lth Cong. 9 (2010) (statement of economist Joseph E. Stiglitz), availableat http://www.gpo.gov/fdsys/pkg/CHRG-1 Ilhhrg61761/pdf/CHRG-1 I lhhrg61761.pdf.

127 Id. at 8 (statement of economist Linda J. Bilmes). Bilmes went on to state, "There aremuch larger social and economic burdens that are not paid by the Federal Government butnonetheless represent a real burden on society. These include the loss of productive capacity byyoung Americans who are killed or seriously wounded; lost output due to mental illness; theburden on caregivers who have to sacrifice paid employment in order to take care of a veteran;the cost of those, particularly among Reservists and Guards, who were self-employed and havelost their livelihood. For many veterans, there is simply a diminished quality of life, the costs ofwhich is [sic] borne by individuals and families." Id. at 10. In another forum, Bilmes stated that,"recent data shows that 331,514 unique returning veterans have been diagnosed with a possiblemental disorder, including 177,149 diagnosed with PTSD." Bilmes, supra note 118 at 3.


C. CHOICE IN THE MILITARY

For service members who have been instilled with the belief that self-sacrifice is essential to the mission of the armed forces,128 takingpsychotropic medications may be seen as the most minimal step one cantake towards ensuring the wellbeing of the group. By taking thesemedications, they are able to continue missions with their fellow servicemembers, who can continue to trust their abilities and count on them forsupport.129 Considering the frequently life-threatening situations in whichservice members in combat settings find themselves, a defense expert hasnoted that "it is very easy to imagine that warriors would consider usingany manner of drug they thought would increase their chance of returninghome alive."' 30 With the pressure of representing the United States ArmedForces, keeping the country safe, and performing one's assigned missionsin an effective manner, it is no wonder that service members would turn tomedications to aid them in these tasks.'31 In America's Medicated Army,Sergeant Christopher LeJeune commented that for himself and his fellowservice members in Baghdad, "It's not easy for soldiers to admit theproblems that they're having over there for a variety of reasons," and that"[i]f they do admit it, then the only solution given is pills." 32

Additionally, service members whose superiors direct them to takepsychotropic medications for the benefit of the group may not seethemselves as having the right to refuse medication. 133 Every othercommand by a superior must be obeyed, and the command by a superiorto take medication-even if merely a suggestion-will likely be seen assomething that must be obeyed.134 Because service members "aren'tnormally asked for their informed consent before accepting what theircommand regards as the best preparation for battle ... it's difficult to seewhy these [augmenting cognition] enhancements should be regardeddifferently from anything else a soldier can be legally ordered to do."

Thus, in the military, choice-in the sense of service members'

128 See supra text accompanying note 44.129 See generally Thompson, America's Medicated Army, supra note 24.130 Knickerbocker, supra note 39.

131 Id.132 Thompson, America's Medicated Army, supra note 24.133 See Annas & Annas, supra note 43 at 300.134 Id.

Id. at 300 (citing JONATHAN D. MORENO, MIND WARS: BRAIN RESEARCH ANDNATIONAL DEFENSE 53 (2006)).

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autonomy to make decisions in their own best interests-is not an option.Indeed, it does not even figure into the equation for most service members,who have been indoctrinated to accede to the commands of their superiorsand to value the best interests of the military over the best interests ofthemselves as individuals.'36 If individual service members begin makingchoices in their own best interests that go against their leaders' commands,they would soon find themselves out of a job. 3 1

D. FAULT IN THE MILITARY

As evidenced in a disturbing example of amphetamine use and itsnegative effects on military pilots, amphetamines can negatively influencedecision-making and patience in combat settings, to disastrous effects.13 8

In April 2002, after misidentifying a target in an Iraqi bombing missionand complaining of fatigue due to unobserved rest periods betweenmissions, Air Force pilots were told to "[s]top whining and visit the flightsurgeon for some 'go/no-go' pills."' 39 One week later and allegedly underthe influence of the "go" pill Dexedrine, two pilots of the same FighterWing misidentified another target and bombed "a Canadian training force,killing four and injuring eight." 4 0 At the pilots' hearing to determinewhether they should be court-martialed for "manslaughter, assault anddereliction of duty," their attorneys argued that Dexedrine was to blamefor the incident.141 Though charges were eventually dropped against one ofthe pilots, the other pilot was found guilty of dereliction of duty and fined,reprimanded, and banned from flying Air Force planes, a pronouncementthat effectively ended his career.14 2

The continued institutionalized use of amphetamines in the Air Forcedemonstrates that in cases like the one described above, "[i]t is much moreconvenient ... to brush the incident off as rash pilots behaving in anarrogant way, rather than perform a complete system review that might

136 See supra Parts 0 and 0.137 Knickerbocker, supra note 39 (stating that "[t]he drugs are legal, and pilots are not

required to take them-although their careers may suffer if they refuse").I3 See Elliot Borin, The U.S. Military Needs Its Speed, WIRED (Feb. 10, 2003),

http://www.wired.com/medtech/health/news/2003/02/57434.19Id.

140 Id.I4 Id.

142 David Stout, Fighter Pilot Found Guilty of Dereliction in Mistaken Bombing, N.Y.TIMES (Jul. 7, 2004), http://www.nytimes.com/2004/07/07/us/fighter-pilot-found-guilty-of-dereliction-in-mistaken-bombing.html?ref-harryschmidt.

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raise more generic safety problems." 4 3 "Colonel Peter Demitry, Chief ofthe United States Air Force Surgeon General's Science and TechnologyDivision, has referred to prescribing amphetamines for pilots as the 'goldstandard for anti-fatigue,"'l 4 4 and that its usage "is a life-and-death issuefor our military." 4 5

E. REPEATED DEPLOYMENTS AND A "STRAPPED" MILITARY

In its present state, the military is overextended: service members arebeing asked to perform more missions than they would if additional troopswere available to continuously replenish them.146 They are aware thatthere is no draft from which to recruit new service members, and that theyare being asked to redeploy more than would be ideal. Due to this lack ofsupply in troop numbers, perhaps the military has no choice but to requestthat service members use drugs in order to manipulate their sleep andwake cycles in furtherance of completing missions successfully.14 7 Indeed,as the military states, its current mission "to fight a long war on multiplefronts with an all volunteer force demands that military personnelresources be tightly conserved. Hence, identifying and treating all healthproblems early so full functional capacity can be restored as quickly aspossible is an important means toward that end." 48 In its guidebook toperformance maintenance for its flight surgeons, the Navy asserts, "Wemanage maintenance, fuel and weapons; we can also manage fatigue." 4 9

To the military, fatigue and other symptoms of stressful, endurance-testingcircumstances are considered issues to be "managed" on par with routineweapon maintenance, as opposed to being considered a mental healthproblem in need of specialized mental health treatment.' 50 The militaryjustifies its position on frequently redeploying service members withpotential mental health risks by posing an ominous question:

If personnel issues were of no concern-if recruits and seasoned veteranswere both in limitless supply and the impact on mental health stigma of

143 Annas & Annas, supra note 43 at 296.144 Id. at 295-96.145 Borin, supra note 138.146 DEP'TS OF THE NAVY & U.S. MARINE CORPS, supra note 1, at 6-10 (stating that,

"[s]ince the modem military is an all volunteer force of limited size, Service members and theirunits must be recycled repeatedly and often").

147 Annas & Annas, supra note 43, at 296-97.148 DEP'TS OF THE NAVY & U.S. MARINE CORPS, supra note 1, at 5-8.149 NAVAL STRIKE & WARFARE CTR., supra note 38, at 5.150 Id.

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personnel policies could be ignored-one way to ensure maximumpsychological readiness would be to quickly separate from active dutyeveryone that showed signs of significant distress or loss of normalfunctioning due to stress ... But what would be the consequences ofsuch an extreme policy?' 5'

Further, the military asserts that absolutely barring service memberswith histories of mental health issues would result in even more hesitationto voice mental health concerns, noting that:

If everyone who sought care for a stress injury were automaticallyseparated from the Service, the only Marines and Sailors who wouldcome forward asking for help would be those who were looking for away out of the Service or those whose impairment or distress hadbecome so profound they could no longer hide it.152

The military compares separating active duty troops with mentalhealth issues to those with physical health issues, explaining that thosewho fully recover from physical injuries should not be barred fromreturning to combat, so those recovering from mental health injuriesshould not be barred either.'53

However, repeated deployments compound the likelihood ofdeveloping mental health problems' 54 due to repeated exposure totraumatic events. 15 The military's Defense Health Board concluded:

The psychological and behavioral effects on Service members ofmultiple deployments and the mental health impact of serving in thecombat settings of Afghanistan and Iraq-dangerous situations for longperiods in extreme environments-are ongoing, growing, and urgentnational concerns. Exposure to deployment-related stressors is linked toService members experiencing elevated rates of post-traumatic stressdisorder (PTSD), acute anxiety disorder, sleep disturbances, anxiety,depression, and substance abuse disorders.156

The risks of mental health issues developing due to repeateddeployments are especially prominent when coupled with insufficientrecovery time between combat tours.'57 Currently, service members

151 DEP'TS OF THE NAVY & U.S. MARINE CORPS, supra note 1, at 6-2.152 Id. at 6-3.153 Id.

JOINT MENTAL HEALTH ADVISORY TEAM 7, supra note 58, at 7.155 Def. Health Bd. Memorandum, supra note 27, at 2.156 Id. at 1.157 DEP'TS OF THE NAVY & U.S. MARINE CORPS, supra note 1, at R-1 (stating that "[t]he

incidence of COS [combat and operational stress] can increase when operating tempo is high

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receive twelve months off between tours, which, according to top Armypsychiatrist Colonel Charles Hoge, does not allow service membersenough time "'to reset' and recover from the stress of a combat tour beforeheading back to war."'ss Moreover, because there is no "frontline" in thecurrent wars, deployed service members must be on guard and preparedfor combat at all times.15 9 Service members may be under near-constantfire and attacks may happen in seemingly benign places:

The nature of this conflict is also quite unusual. As in Vietnam, theenemy blends in with civilians, rendering everyone a potential threat; butunlike in Vietnam, this war is fought in cities as much as in thehinterlands, which means soldiers are never allowed to mentallydecompress. There's no front in this war, and no rear either, whichmeans there's no place to go where the mortar rounds aren't.160

As a result of this constant tension, service members develop"unremitting combat anxiety" and have no time to "mentallydecompress,"'61 further multiplying their stress levels.

F. CONSEQUENCES OF DISOBEYING A SUPERIOR'S COMMANDREGARDING MENTAL HEALTH TREATMENT

The increased prevalence and acceptance of psychotropicmedications for service members in combat settings has resulted inprescriptions entering the picture even before a service member isdeployed. According to one New York psychiatrist who spoke with theLos Angeles Times, despite the fact that "maybe 10 or 12 years [ago], youcouldn't even go into the armed services if you used any of these drugs, inparticular stimulants .... I'm getting a new kind of call right now, andthat's people saying the psychiatrist won't approve their deploymentunless they take psychiatric drugs." 6 2 Service members who have beendiagnosed by a military physician as needing to take psychotropicmedications to be fit for deployment cannot continue their careers in themilitary without heeding such a directive.16 3

Returning to the Air Force's sanctioned use of amphetamines

due to multiple 'back to back' deployments/extended combat operations").158 Thompson, America's Medicated Army, supra note 24.

'5 Senior, supra note 6.160 Id.161 Id162 Murphy, supra note 18.163 See Winkenwerder Memorandum, supra note 20, at 4.1.4 to 4.2.

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discussed in Part IV.E, a pilot who receives Dexedrine must sign aninformed consent form that "mentions the voluntary nature of the programno fewer than seven times," but also includes a statement that "the pilotcan be grounded for exercising his right not to imbibe."'" To be"grounded" means to be taken off flight status, effectively ending a pilot'sduties and possibly career.' 65 Retired Air Force officer Major GlennMacDonald commented that through such a policy, the Air Force "wascoercing its pilots to possibly become drug addicts and endangering theirhealth." 66 The threat of losing one's job if a service member refuses totake psychotropic medication indicates there is no meaningful choice formembers of the Air Force as to whether to take the amphetamines.

Moreover, all consequences generated from the decision to take ornot to take a psychotropic medication are borne by the individual servicemembers. For an Air Force pilot, refusing to take Dexedrine may result inbeing grounded and losing his or her career.' 6 7 Conversely, agreeing totake Dexedrine may result in an inability to properly perform one'smission, and in some instances, can have tragic consequences, 6 8 with soleresponsibility placed on the individual.

VII. IMPLICATIONS OF THE USE OF PSYCHOTROPICMEDICATIONS FOR MILITARY PHYSICIANS

As opposed to civilian physicians, military physicians are in aparticularly sensitive position in terms of prescribing psychotropicmedications.' 69 Whereas a physician's primary duty of care is to thepatient, military doctors must consider implications of treatment not onlyfor an individual's health, but also for the wellbeing and safety of acombat mission and the military on a larger scale.' 70 Military physicianshave pledged not only the Hippocratic Oath to "uphold a number ofprofessional ethical standards" and "do no harm,"' 7' but also have taken a

164 Borin, supra note 138.165 See id.166 Id.167 Id.168 See supra note 72 and accompanying text.169 See Victor W. Sidel & Barry S. Levy, Physician-Soldier: A Moral Dilemma?, in

MILITARY MEDICAL ETHICS VOLUME 1 296 (Thomas E. Beam et al. eds., 2003), available athttps://ke.army.mil/bordeninstitute/published_volumes/ethicsVol I /Ethics-ch- Ill.pdf.

170 See id. ("[Tihe ethical principles of medicine make medical practice under militarycontrol fundamentally dysfunctional and unethical.").

171 HISTORY OF MED. Div., NAT'L INST. OF HEALTH, GREEK MEDICINE-THE

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REVIEW OF LA WAND SOCIAL JUSTICE [Vol.22:2

military oath and are members of the military.17 2

Indeed, the motto of the American military physician is "[T]oconserve the fighting force."' 7 3 While seemingly a well-intentionedphrase, it hints eerily at the notion that military physicians should be moreinterested in preserving military resources by certifying existing servicemembers as fit for combat, despite any health concerns. 174 According tothe former chair of the President's Council on Bioethics, "medical ethicsare and must be the same for civilian and military physicians, 'except inthe most extreme exigencies."" 75 Likewise, the editors of MilitaryMedical Ethics insist, "'instances of significant conflict' between civilianand medical ethics are 'very rare."" 76 Still, it is the individual physician'sresponsibility "to reflect on how his personal values relate to being aphysician in the military in war and peace. In particular, the physician-soldier needs to reflect on the concept of conservation of force and hisresponse and responsibilities to it."' 77 The underlying message appears tosubvert individual-centered care in favor of care for the military as awhole.'

HIPPOCRATIC OATH (Michael North trans., Nat'l Library of Med., 2002), available athttp://www.nlm.nih.gov/hmd/greek/greekoath.html (last visited Apr. 13, 2013).

172 See William Madden & Brian S. Carter, Physician-Soldier: A Moral Profession, inMILITARY MEDICAL ETHICS VOLUME 1 271 (Thomas E. Beam et al. eds. 2003), available athttps:/Ike.army.mil/bordeninstitute/published-volumes/ethicsVoll/Ethics-ch-10.pdf. "Physiciansare made a part of that military system in a very formal way. They are sworn in as members ofthe profession of arms, taking the same oath as those who lead in combat. They wear the sameuniform, have the same rank and title system as other soldiers, and are given the privilegesgranted by society to the profession of arms. These physician-soldiers also take at leastrudimentary training in basic military skills and are issued a weapon when there is a threat totheir well-being." Id.

173 Annas & Annas, supra note 43, at 287.174 See id.175 Id. at 300-01. The former Chairman also stated that, "[T]here are no special medical

ethics for active-duty military physicians any more than there are for Veterans Affairsphysicians, National Guard physicians, public health physicians, prison physicians, or managedcare physicians." Id. at 301 (citing Edmund D. Pellegrino, The Moral Foundations of thePatient-Physician Relationship: The Essence of Medical Ethics, in MILITARY MEDICAL ETHICSVOLUME 1, (Thomas E. Beam et al. eds., 2003), available at https://ke.army.mil/bordeninstitute/published_volumes/ethicsVoll/Ethics-ch-l l.pdf).

176 Annas & Annas, supra note 43, at 301.177 Madden & Carter, supra note 172, at 285.

See George J. Annas, Military Medical Ethics-Physician First, Last, Always, 389 NEWENG. J. MED. 1087, 1087-89 (2008) [hereinafter Annas, Military Medical Ethics].

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WHOSE CHOICE?

A. THE PHYSICIAN-SERVICE MEMBER RELATIONSHIP

In addition to the many pressures service members face, a seeminglyunexpected one may arise in the context of their relationship with militaryphysicians. To have the physician-patient relationship compromised as aresult of overriding pressure to "conserve the fighting force" furthercomplicates the issue of service members relinquishing their autonomyand choice.' 79 If there exists any place for individual choice in the military,it would seemingly be present in the choice to make informed decisions inone's healthcare. However, a physician's simultaneous oaths of loyalty toboth the service member and the military compromises the physician'sability to be fully forthcoming with the best interests of the individual. 80

B. CERTIFYING TROOPS FOR REDEPLOYMENT

Because of the duration of the wars in Iraq and Afghanistan and therelative shortage of troops,' 8 ' preservation of the existing troops' health isimperative for the Department of Defense.' 82 More troops are receivingmental health treatment for serious mental disorders such as depressionand anxiety than in previous wars; suicide rates of enlisted personnel andveterans are at all-time highs.'83 Indeed, in order to retain service membersin combat areas or return them for another deployment, militaryphysicians are increasingly prescribing psychotropic medications,particularly selective serotonin-reuptake inhibitors, when faced withservice members experiencing depression, anxiety, and PTSD.184

In America's Medicated Army, journalist Mark Thompsoninterviewed Colonel Joseph Horam, a doctor who was deployed to "SaudiArabia during the first Gulf War and has been deployed twice to Iraqduring [the current] war."' 85 Colonel Horam noted that during the firstGulf War, "stressed troops [were given] a little rest and relaxation to see if

179 See id. (quoting David M. Benedek, et al., Psychiatric Medications for Deployment: AnUpdate, 172.7 MIL. MED. 681, 685 (2007)). See also Henry Greely et al., Towards ResponsibleUse of Cognitive-Enhancing Drugs by the Healthy, 456 NATURE 702, 704 (2008) (stating thatcoercion and autonomy are relevant concerns for those in the military).

180 See Annas, Military Medical Ethics, supra note 178, at 1087-89.181 Annas & Annas, supra note 43, at 304.182 Thompson, America 's Medicated Army, supra note 24.183 Id.inId.

184 Id.185 Id.

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they improved," and if they did not, they were likely sent home.,86

Conversely, Colonel Horam detailed the treatment of one patient, a guardof Iraqi detainees, in Baghdad in 2006:

He was distraught while he was having high-level interactions withdetainees, having emotional confrontations with them-and carryingweapons. ... But he was part of a highly trained team, and we didn'twant to lose him. So we put him on an SSRI [Selective SerotoninReuptake Inhibitor], and within a week, he was a new person, and we gothim back to full duty. 87

Colonel Horam did not comment on whether the patient experiencedany long-term effects from the circumstances of his treatment. At aNational Institutes of Health conference in December 2010, ColonelChristopher Robinson of the United States Air Force described hisdeployment to Afghanistan as a Combat Stress Detachment Commander,where he oversaw "35 mental health professionals spread across 11forward operating bases around the eastern part of the country."' 88 ColonelRobinson stated, "[O]ur focus is on keeping servicemembers in the fight-providing outreach to platoons with the highest levels of combat."' 89 Ofthe service members that Robinson and his team dealt with, ninety-twopercent "were eventually returned to duty without limitation," whereas sixpercent "were returned with limitations." 90 Despite the admirableintentions of providing more mental health outreach, it seems that militaryphysicians, at least on some scale, are putting the interests of an exhaustedmilitary looking to keep valuable members in key positions ahead of themental health of individual service members.191

The Pentagon set a uniform policy for mental health services inNovember 2006, but explicitly absent from the policy was any directive onnewly-available anti-depressants.192 According to an individual whoparticipated in crafting the Pentagon policy, "the goal ... was to giveSSRIs [Selective Serotonin Reuptake Inhibitors] a 'green light' without

186 Id.187 Id.188 Military Challenged to Provide Far-Forward Mental Health Care, U.S. MEDICINE, THE

VOICE OF FEDERAL MEDICINE, http://www.usmedicine.com/psychiatry/military-challenged-to-provide-far-forward-mental-health-care.html (last visited Apr. 13, 2013).

I89 Id.190 Id.

191 See id.192 Thompson, America's Medicated Army, supra note 24.

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WHOSE CHOICE?

saying so."' 9 3 In the absence of any military doctrine on SSRI use incombat settings, some military psychiatrists have recommended that theircolleagues going to Iraq and Afghanistan "should consider having oneSSRI in large quantities, to be used for both depressive disorders andanxiety disorders' to . . . 'conserve the fighting strength."'l 9 4

In the Navy's guidelines for performance maintenance, the SurgeonGeneral of the Navy writes that the directive was a response to "the fleet'srequest to use stimulant and sedative medications during continuous andsustained flight operations."' 95 He then notes that the directive and itsapproval of using medications for those purposes demonstrate "NavyMedicine's commitment to fulfill its primary mission-support to thefleet." 96

VIII. CONCLUSION

One of the most easily foreseen consequences of war is its toll on themental health of service members, both during and after theirdeployments.19 7 Due to the enormous sacrifice that United States servicemembers make on behalf of their country, the United States governmentmust similarly devote effective and sufficient mental health treatment forthese troops.

The pervasive nature of psychotropic medication use in the armedforces prompts the question of whether individual service members feelpressured out of a sense of duty to take medication to be able to remaindeployed, whether the general macho culture of the military discouragesservice members from voicing concerns about their own mental health, orwhether it is the result of an increasing military culture of doctorsprescribing pills to certify troops for redeployment or to remaindeployed.' 98

The military's awareness of the stigma associated with mental healthissues has led it to outline certain suggestions to improve the situation,including more explicit communication of mental health policies and any

193 Id.194 Annas & Annas, supra note 43, at 304.

195 NAVAL STRIKE & WARFARE CTR., supra note 38, at 4.19 6 1d.

1 See Thompson, America's Medicated Army, supra note 24.198 DEP'TS OF THE NAVY & U.S. MARINE CORPS, supra note 1, at 5-3; see also Thompson,

America's Medicated Army, supra note 24.

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implications (or lack thereof) associated with seeking treatment. 19 9

Commanding officers are encouraged to "continually monitor" the fitnessof service members who have received mental health treatment and to"mentor them back to full duty as they recover." 2 00 Stigma is to be"continuously addressed" in order to dissipate the mystique surroundingand prejudicial feelings toward mental health issues.2 01

Despite such recommendations, it remains to be seen whetherinstitutional change on mental health issues will soon be implemented andeffective in the military. Meanwhile, reports of continued stigma,continued pressure to hide mental health issues, continued pressure to takepsychotropic medications, and continued lack of monitoring of servicemembers' mental health concerns persist. 20 2 Service members have beentaught noble lessons of selflessness and to strive for the greater good.2 03

Yet through its policies on mental health issues and overallinstitutionalized coercive nature, the military is manipulating its servicemembers into sacrificing beyond what is helpful or healthy for eitherthemselves as individuals or the general mission of the military. Finally, ifit is true that the military has no choice but to request that servicemembers sacrifice their own individual wellbeing for the greater good ofthe fighting force, the military needs to accept responsibility for exertingsuch coercion. When faced with negative, perhaps devastating,consequences ansing out of a decision to take or not to take psychotropicmedications, the military must accept responsibility and share blameinstead of letting the guilt fall solely onto the shoulders of individualservice members.

199 DEP'TS OF THE NAVY & U.S. MARINE CORPS, supra note 1, at 5-5.200 Id. at 1-20.201 Id.202 See Thompson, America's Medicated Army, supra note 24; DEP'TS OF THE NAVY &

U.S. MARINE CORPS, supra note 1, at 3-7.203 DEP'TS OF THE NAVY & U.S. MARINE CORPS, supra note 1.

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